We reported two cases of conduction aphasia with distinctive language disorder from early stage of stroke, as well as their cerebral blood flow and oxygen consumption investigated with PET.
The case was a 72-year-old right handed man whose speech disturbance began acutely. On admission, neurological examination revealed hand pronation sign on the right and speech disturbance. Other neurological findings including cortical functions were normal. Brain CT scan showed low density area in the white matter of the left supramarginal gyrus. The diagnosis was cerebral infarction.
The case 2 was a 64-year-old right handed man. He suffered right hemiparesis 2 months before. Neurological examination revealed mild right hemiparesis and speech disturbance. Other cortical functions were noncontributory. Brain CT scan showed old subcortical infarction of the left frontal lobe and new cerebral infarction with supramarginal gyrus. The low density area of the supramarginal cortex extended into the subcortical white matter.
The language performances in these two cases were similar. Two patients were definitely fluent, but the verbal output was contaminated by paraphasias which were predominantly literal. They performed poorly when attempting to repeat despite good comprehension. Thus, the primary characteristics of conduction aphasia were present.
PET studies resulted as follows. 1) rCBF reduced 36% in the supramarginal cortex, 50% in the white matter. 2) rCMRO₂ reduced 37% in the supramarginal cortex, 45% in the white matter. 3) The CBF and the CMRO₂ images indicated that cerebral blood flow and oxgen consumption reduced in wider range of area than that shown by brain CT.
These results indicated that not only the cortex but also the white matter were damaged in conduction aphasia and several methods including PET should be used to determine the locus of abnormality in conduction aphasia.

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Influences of magnesium, calcium and associate minerals to cerebral blood flow and brain function were studied in 66 normal aged people (31 males, 35 females, mean age of 75.6 years). The concentration of magnesium, calcium, phosphate, sodium and potassium in hair which were thought possively reflected whole body storage were measured by ICP method (Japan midical preventive system). The regional cerebral blood flow (rCBF) was measured by ¹³³Xe inhalation method.
1) There were no significant relationships between age, mean blood pressure and these minerals in hair.
2) Mean rCBF showed significant correlation with magnesium and calucium in hair (r=0.48 and r=-0.35 respectively) and inverse correlation with phosphate (r=-0.27).
3) Verbal and performance intelligences and self-rating depression score (SDS) did not show significant correlation with these minearals in hair.
4) Females showed significantly higher magnesium and calcium in hair than that of males, and rCBF of females was also higher than males. But there were no sex-differences in intelligences and SDS.

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Blood pressure (BP) control is urgent for the management of patients with acute hypertensive cerebral hemorrhage (AHCH). However, there is little information concerning how far BP can be safely reduced in patients with AHCH. The authors provided following hemodynamic investigation to clarify the lower limit of BP in the treatment of AHCH.
Thirteen patients with supratentorial AHCH, whose habitual BP before ictus was known, were subjected in this study. In all cases, size of hematoma was medium, as estimated by CT scans. During acute stage, BP was gradually reduced by intravenous administration of trimetaphan camsilate combined with head-up tilting. The rate of cerebral blood flow (CBF) changes were repeatedly measured by the arteriovenous oxygen difference method. Blood pressure was measured with transducers. Lower limit of BP was estimated from BP-CBF relationship curves, and relationships between lower limit and habitual mean arterial BP (habitual BP) as well as post-ictal BP before treatment was investigated. In two cases, BP-CBF relationship were tested in both acute and chronic stage.
The results were summerized as follows :
1) Autoregulatory response was maintained to a certain extent in the majority of cases.
2) Lower limit of autoregulation was almost equal to pre-ictal habitual BP.
3) Lower limit of autoregulation varied in each case, however, it existed almost always at the level corresponding to 80% of post-ictal BP measured before treatment.
4) In one case, lower limit of autoregulation was slightly higher than habitual BP in acute stage of ictus. However, in chronic stage, the lower limit was lowered below habitual BP. The other case, dysautoregulation pattern was seen in acute stage of ictus, but autoregulatory range was appeared in chronic stage.
The present study suggested that 20% reduction of post-ictal BP was considered to be maximum during acute stage, but not below habitual BP level.

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We reviewed 220 patients with hypertensive intracerebral hemorrhage (ICH) to study on the time of completion of hemorrhage after the onset and performed the statistical analysis as follows. The incidence of hypertensive ICH was approximately 42/100, 000/year and was higher in spring (March, April and May) and later fall (October and November). There was a male preponderance which was especially evident in pontine and putaminal hemorrhages. Twenty-two patients had accompanying cerebral infarctions with ICH and 12 patients had multiple or recurrent ICH's. This indicates that there is a higher risk of recurrent apoplexy in the patients who have a past history of cerebral infarction or hypertensive ICH than in others. In 74 patients who had serial CT scans to investigate whether the ICH enlarged or not, 63 were found unchanged in size, 7 slightly enlarged and only 4 markedly enlarged. Nine of the latter 11 patients with enlargement of ICH were cases who had CT examinations within 1 hour after the onset and the other two patients had CT scans within 2 hours after the onset. These results suggest that the completion of hypertensive ICH may take place within 2 hours after the onset, probably within 1 hour in most patients. Intensive lowering of blood pressure should be done in the very early period after the onset as a first step of the treatment of hypertensive ICH.

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A series of 80 patients with cerebrovascular accidents below the age of 40 was studied to determine what factors had influenced returning to their premorbid social functions. They were refered to the Central Rehabilitation Service of University of Tokyo Hospital from 1975 to 1984. The possible effects of age, sex, pathological difference between hemorrhage and infarction, affected sides, complication of aphasia or other higher cognitive dysfunctions, severity of hemiplegia, duration from the onset to the first visit to our center, cardiac disease, recurrence of stroke and premorbid occupation or social state were analyzed.
Nineteen of the 35 patients with intracranial hemorrhage and 35 of the 45 patients with cerebral infarction returned to work. Chi-square analysis showed that the outcome of hemorrhagic cases had been significantly worse than that of infarction cases (p<0.05). Significant differences were also noticed in the factors of affected sides and disturbances of higher cognitive functions (p<0.01). And then, multivariate analysis method was undertaken to analyze these factors more accurately. The results revealed that the paresis of right or bilateral sides and the severe hemiplegia had made the outcome worse. With regard to social state, pupils and students had been more likely to return to their school life. Since multiple correlation coefficient from these items was 0.669, that was not sufficient to explain whole factors influencing return to work, further factors should be considered, especially in the nonmedical fields.

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The intravascular use of alkyl-α-cyanoacrylate in 3 patients with intracranial arteriovenous malformations is described. The monomer was introduced into each nidus at craniotomy through the main feeding arteries, while temporal clipping of the feeding arteries was performed. Total excisions of malformations were done under minimal bleeding. No complication was noted.
The problem of this procedure is to occlude normal vessels by the overflow of the monomer from the nidus, and to pass through the AVM and occlude venous side. We should study adequate speed for injection or amount of the monomer.

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Electrical stimulation of the median nerve during voluntary contraction of abductor brevis (APB) muscle produces the direct muscular response (M wave) and a few late responses such as V1 and V2 responses. V2 response (C-response) is considered to be a transcortical long-loop reflex, although the origin and the pathway of this wave are still obscure. We recorded surface EMG of APB muscle and somatosensory evoked potentials (SEPs) simulatneuously in normal subjects and patients with well-localized cerebrovascular diseases to study the supraspinal pathways of V2 response. Surface EMG and SEPs recorded from Erb's point (Erb), the seventh cervical spine (CV7) and the contralateral postrolandic portion (C3 or C4) were averaged when 100-256 electrical stimulation (pulse width : 1 ms, stimulus strength : just above the threshold for M wave) were applied to the median nerve at the wrist. Subjects were asked to contract the APB muscle with constant force (about 1 kg) during recording.
In normal subjects, onset and peak latencies of V2 response were 47.2 ± 5.2 ms and 53.1 ± 5.4 ms respectively. N9, P/N13 and N19 components of SEPs appeared with normal latencies. In patients with thalamic lesions, V2 responses and N19 components of SEPs were absent when stimulations were given to the affected side. SEPs obtained from a patient with a lacunar infarction in the posterior limb of the internal capsule appeared normal, while V2 response was not observed by paretic side stimulation. In a patient with a small pontine hemorrhage involving the medial lemniscus at the lower pons, SEP recorded from C3 showed no significant peaks and V2 response was not evoked by affected side stimulation.
These results suggest that dorsal column-lemniscal pathway and pyramidal tract might be involved in the pathway of V2 response.

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Rat cerebral vessels in ischemic lesions, introduced by plugging a silicon rubber cylinder into the terminal segment of the unilateral internal carotid artery, were investigated under an electron microscopy, immediately after either ischemic period or recirculation-period following ischemia. Recirculation into ischemic lesion was achieved by pulling the cylinder out from the artery.
The denudation of endothelial cells from the basement membrane was observed in the small arteries of animals having persistent ischemia for more than 6 hours. On the contrary, in a recirculation group with occlusion for 2 hours was enough for occurring endothelial denudation of the artery in ischemic lesions, if it received recirculation for 2 hours.
Ultrastructural changes of medial smooth muscle cells in the arteries, such as swelling and destruction of mitochondrial cristae and cytoplasmic swelling leading to disappearance of contractile cytoplasmic filaments, preceeded endothelial denudation. Accordingly, medial smooth muslce cells seemed to be more vulnerable against ischemia than endothelial cells.
Endothelial denudation surely exacerbated vascular changes so that medial necrosis appeared to be accomplished beneath the denuded areas and erythrocytes, platelets and carbon particles were allowed to be leaked into the media from the lumen to permeate into cytoplasmas of smooth muscle cells. Contrary to arteries, veins in the infarcted areas did not show endothelial denudation nor medial necrosis. As duration of occlusion was longer, arterial lesions were more intense resulting in more marked increase of vascular permeability.

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It has been recently recognized that the leukotrienes C₄, D₄ (LTC₄, D₄) synthesized from arachidonic acid by 5-lipoxygenase have a potential action on vascular tone and permeability. The purpose of this study is to elucidate the role of 5-lipoxygenase products in experimental cerebral vasospasm.
Sixty cats were subjected in this study. Three days after the injection of 3 ml of autologous blood into the cisterna magna, the basilar artery was exposed by the transclival approach.
Topical application of TxA₂ analogue (STA₂) 1 ×10^-8M 1 ×10^-6, LTC₄ 1 × 10^-6M 1 ×10^-4M, and LTD₄1 × 10^-6M 1 ×10^-4M to the basilar arteries, produced a dose related constriction of the arteries.
Experimental cerebral vasospasm was produced by the continuous irrigation of the basilar artery exposed transclivally, with the mixture of blood and CSF incubated for 3 days at 37°C. The continuous irrigation was maintained for 2 hrs at the rate of 0.5 ml/hr. The caliber of basilar artery and rCBF of pontine tegmental region were measured simultaneously by microphotography and heat and hydrogen clearance methods. Platelet aggregation studies were also performed.
Cats were divided into 3 groups : non-treated cats, and cats treated with 5-lipoxygenase inhibitors : AA-861 (500 μg/kg/min), NDGA (300 μg/kg/min), Phenoxazine (5 μg/kg/min), ONO-5349 (100 μg/kg/min), and LTC₄, D₄ antagonist : FPL-55712 (200 μg/kg/min). In treated cats, intravenous infusion of the agents was begun 30 min prior to the production of cerebral vasospasm and maintained through the experiment.
In non-treated cats, the caliber of basilar artery decreased 29.2 ± 4.4 (mean ± SE) % of its original diameter 10 minutes after the irrigation of blood-CSF mixture and remained unchanged as long as it was irrigated. Ten minutes after the irrigation, rCBF of pontine tegmentum was 24.4 ± 1.5 ml/100 g/min and gradually decreased further to the level of 18.6 ± 1.4 ml/100 g/min.
In treated cats, basilar artery became spastic as well. The degree of vasospasm was almost same as compared with non-treated cats. However, the gradual reduction in rCBF was prevented. rCBF of the pontine tegmentum rather increased even in animals with severe cerebral vasospasm. There was no difference in pharmacological effects among 5-lipoxygenase inhibitors and LTC₄, D₄ antagonist. Both 5-lipoxygenase inhibitors and LTC₄, D₄ antagonist did not inhibit platelet aggregation.
These results suggest that 5-lipoxygenase products may not have an important role in the development of cerebral vasospasm in the major vessels, but may constrict the small arteries resulting in the decrease of a cerebral blood flow.

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Eighty cases of Terson's syndrome including 5 personal cases were reviewed. All of 5 personal cases had severe subarachnoid hemorrhage (SAH) : two were at grade IIIb on admission, two had major attack associated with unconsciousness lasting more than 3 hours, two experienced re-rupture, and one had received no medical treatment for 14 hours after the last attack. CT scan showed thick subarachnoid clots in four (Fisher's group III), intracerebral hematoma in two, and acute hydrocephalus in two. The vitreous hemorrhage was noted on the side on which the SAH was much more severe.
The overall incidence of vitreous hemorrhage was 2.50% (48 patients) of a total of 1918 patients with aneurysmal SAH reviewed in this paper. When the distribution of the aneurysm in this series is taken into consideration, the rate of association of vitreous hemorrhage was significantly higher (p<0.05) in the aneurysm of the anterior communicating artery, and lower in the aneurysm of the middle cerebral artery or the distal anterior cerebral artery. Outcome of SAH associated with vitreous hemorrhage is grave; the patients died or the outcome was poor in 34%, and the outcome was fair in 30%. When the patients survived, however, the prognosis of visual function is relatively good. Functional vision was retained in 69% of patients treated conservatively, and in 92% of patients who underwent vitrectomy.

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Duplex ultrasonography (Duplex) is combined with high resolusional B-mode scan (B-mode scan) and pulsed Doppler spectral analysis system (pulsed Doppler system). It is reported that Duplex is very useful in the diagnosis of extracranial vascular occlusive disease.
We examined 17 patients with internal caortid artery occlusion by extracranial caortid Duplex examination in the neck and found that this examination was very useful in the diagnosis of internal cartid artery occlusion.
In this study there were 12 patients with internal carotid artery (ICA) origin occlusion and 5 patients with siphon occlusion.
In 12 patients with ICA origin occlusion, we can image thrombus in the ICA origin lumen in 7 of 12 patients by only B-mode scan and cannot detect blood flow by the pulsed Doppler system in all 12 patients. So Duplex can diagnose all ICA origin occlusion patients.
In all 5 siphon occlusion patients, there is no abnormality in B-mode scan examination. But in the pulsed Doppler system examination, bloood flow was zero during diastolic phase and blood flow was detected only during systolic phase. This Doppler flow pattern was obviously distinguished with that of contorol patients.
From these results Dupplex can not only diagnose ICA occlusion but also point out localization of obstructive lesion. So Duplex is very useful in the diagnosis of extraand intracranial ICA occlusion.

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Serum potassium was measured in 161 patients with acute stroke. All patients were admitted within 24 hours of onset.
The mean value of 3.63 ± 0.05 mEq/l for serum potassium obtained from 96 patients with cerebral hemorrhage was significantly lower than that of that of 4.02 ± 0.05 drawn from 65 patients with cerebral infarction (p<0.01). According to the level of consciousness on admission, patients with cerebral hemorrhage were divided into two groups; responsiveness and unresponsiveness. The mean value of serum potassium (3.43 ± 0.08 mEq/l; n=40) for patients with unresponsiveness was significantly lower than that (3.79 ± 0.09; n=35) for patients with responsiveness (p<0.01). The decreased level of serum potassium were also observed in patients with poor prognosis. In addition, the level of serum potassium significantly correlated with levels of blood glucose and plasma epinephrine (r=-0.307, p<0.01; r=-0.412, p<0.05; respectively).
Although precise underlying mechanism is not clear, it is postulated that hypopotasemia following acute stroke might be due to influx of potassium from extracellular space as a stress reaction.

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A case of persistent primitive hypoglossal artery (PHA) associated with multiple cerebral aneurysms is reported.
A 48-year-old man with sudden headache was admitted to Fukuyama hospital on October 16, 1985. Computed tomography scan revealed subarachnoid hemorrhage. Cerebral angiography showed a ruptured aneurysm of the left distal anterior cerebral artery, an unruptured aneurysm of the anterior communicating artery (AComA) and PHA on the left side. He was undergone neck clipping of aneurysm of the left distal anterior cerebral artery. He was admitted to our hospital for the neck clipping of an unruptured AComA aneurysm on February 3, 1986.
On admission, neurological examination showed slight sensory and motor disturbance of right upper and lower extremities. Modified reverse Stenvers view showed an enlarged hypoglossal canal on the left side. Left carotid angiography revealed PHA and aneurysm of AComA. On February 19, 1986, neck clipping of AComA aneurysm was successfully performed.
A review of 20 cases (25 aneurysms) on PHA associated with cerebral aneurysm including present case was made. 8 aneurysms (32.0%) out of 25 arose from PHA itself, and 4 (16.0%) from vertebro-basilar system. The aneurysms in 3 (12.0%) excluding PHA aneurysms were on the same side with PHA, and in 6 (24.0%) on the opposite side. With these findings, it is concluded that increased hemodynamic stress on PHA and vertebrobasilar system as well as the genetic error of cerebral vessels including the defect of media may play an important role in the occurrence of cerebral aneusysm.

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A 31 year-old man had intermittent headache for a week before admission. Because of the progressive headache and altered level of consciousness, he was brought to our hospital. On admission he was already alert, and no neurologic deficits could be elicited. CT scan of the brain showed no remarkable change except slight brain edema and no neoplasmas nor other space occupying lesions could be seen. The lumbar puncture showed intracranial hypertension. Intravenous digital subtraction angiography (DSA) demonstrated a defect of the left transverse sinus. No other apparent causes of the intracranial hypertension could be found. In this case, the intracranial hypertension was thought to be due to left transverse sinus thrombosis. In cases of an unexplained headaches, benign intracranial hypertension should be considered and intravenous DSA is an expedient, accurate and safe procedure for demonstrating intracranial venous lesion.

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